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COLLECTIVE INVESTING FOR GREATERCOMMUNITY IMPACT

CCO Oregon Innovations In Primary Care ConferenceSean Hubert, Chief Housing & Strategy OfficerRachel Solotaroff, MD, Chief Executive Officer

January 30, 2018

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OVERVIEW

• Describe the Housing Is Health Collective Impact Initiative

• Provide context that supported development of this collaboration

• Understand financial drivers for collaboration + Social ROI

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The Housing Is Health Initiative

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CENTRAL CITY CONCERN’S SCOPE

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MAKING HEADLINES: HOUSING IS HEALTH• $21.5 million donation from six

health systems toward 379 units of housing and new health center announced in Fall 2016.

• National news including New York Times, Washington Post and ABC News.

• Generated interest from industry leaders from: Corporation for Supportive Housing, National Healthcare for the Homeless, Mercy Housing and the Low Income Investment Fund for The California Endowment andThe Kresge Foundation, Kaiser Family News, Funders Together and more.

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HEALTH AND HOUSING COLLABORATIVE

“In health care, we are moving from a focus on caring for disease and acute illness toward ongoing care and treatment of a patient’s overall needs. We know that access to housing helps stabilize people’s lives—and as a result, puts them in a better position to get the best level of care to keep them well.”

-Dave Underriner, Chief Executive, Providence Health & Services – Oregon

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HEALTH AND HOUSING RESULTS

• Three new buildings that will add 379 units of affordable housing to the Portland area

• Includes a new health clinic in East Portland

Coming in 2018-19

Blackburn Building –Housing: 175 units

Integrated Health Clinic

Stark Street Apartments153 units

Charlotte B. Rutherford Place51 units

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BLACKBURN CLINIC CARE MODEL

• Multidisciplinary teams include:• Physicians and midlevel

providers • Social workers, counselors,

peers, and case managers• Employment Specialists• Resident Services

• A trauma-informed and person-centered approach

• A housing and treatment choice framework

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BLACKBURN HOUSING 175 units of Housing:

• Housing for individuals with serious illness Housing for people with substance use disorders

• Housing for people living with mental illness

Leverage 175 beds into 2-3,000 people served every 3-5 years

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Providing Context: How Did We Get Here?

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Individual FactorsPoverty

Early childhood adverse experiences

Mental health and substance use disorders

Personal history of violence/TBI

Criminal justice system interaction

Youth: family conflict/victimizations, non-heterosexual sexual identify, having been in childhood welfare system

Age greater than 50 years old

HOMELESSNESS

Structural Factors*

Absence of affordable housing

Wage stagnation

Unemployment for low-wage workers

*When structural support isnot available, individuals with fewer individual vulnerabilities become homeless and rates of homelessness rise

Fazel et al Lancet 2014

Why are people homeless?

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CONTEXTUAL SHIFT: AFFORDABILITY CRISIS -> HOUSING AND HOMELESSNESS CRISIS

• Housing scarcity and rapid decline in affordability due to:

• Great Recession/Cessation in housing production

• Portland’s population growth

• 2006-2016: Portland was underbuilt by 27,000 units while 190K moved to region

• Shelter and transitional housing outflow slowed; rent and motel vouchers became harder and harder to use.

• This impacted not just non-profits and housers, but health systems which relied on these systems

• Employers started to feel the housing crunch impact on their employees

• Middle class families were being impacted

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CURRENT HOUSING PARADIGM• Shortage of affordable housing:

100,00 state / 30,000 Portland

• What the market is building: less than 1% affordable

• What the public funders are building: 90% affordable at 50% MFI and above

• Limits of the sources being utilized (LIHTCs), leaves populations and care approaches unaccounted for

• High cost, high need population needs are not being met

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EMPLOYMENT CONTEXT

• Labor participation rates > Great recession > Youth and long term unemployed

• Opioid Epidemic and Labor Participation:• As the county unemployment rate increases by one

percentage point, the opioid death rate per 100,000 rises by 0.19 (3.6%) and the opioid overdose ED visit rate per 100,000 increases by 0.95 (7.0%)

• Nearly half of “prime age” men who aren’t in the labor force take pain medication daily

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The Homeless are Aging“Homelessness in the 90’s was a problem of young adults, and “youth is the single best defense against illness “. No longer. Today the people sleeping in shelters, under overpasses and on park benches look more like your grandfather than your younger brother.”

“People over 50 are the fastest growing segment of the homeless population, and they are battling more chronic physical and mental conditions that homeless people in the previous generation. “

From “With the population on the streets aging, homelessness mimics a chronic disease”, Carla Bezold.

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The Opioid Epidemic and Homelessness

• More than 3 million syringes exchanged in 2015, a 59% increase since 2012.

• More than 6,000 unique clients served in 2015

• 40% of syringe exchange clients were homeless; an additional 27% reported an unstable housing situation

• More than half of heroin users surveyed wanted to quit or cut down but report many barriers to treatment.

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Portland’s 2017 Point In Time Count

High Rates of Disability, Especially Among Unsheltered

Of the 4,177 people counted, 2,527 (60.5%) reported living with one or more disabling conditions

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HOMELESS HEALTH CONTEXT

• Opioid epidemic

• Aging of the homeless population nationally

• Increasing disability

• Medicaid plans witnessing increases in cost and utilization trends –unsustainable pattern

• Need for coordinated interventions

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Developing the Financial Case + Social ROI

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LEARNING FROM LOCAL MODELS: BCC

From Providence Center for Outcomes Research & Education:

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Medical Respite Programs Decrease Hospital Readmissions

**NOTE: Many studies have demonstrated that a typical readmission rate for individuals experiencing homelessness is 50%.

Learning From Local Models: RCP

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Clients who entered Recovery Housing after detox were:

3 times as likely to complete SUD treatment

10 times as likely to engage in primary care at OTC

n=1,046; all results are statistically significant at p < 0.001 level; adjusted for drug of choice, age, gender, and race/ethnicity

Learning From Local Models: CCC Recovery Housing

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Lower Behavioral Health Care Cost with RH

Differences are statistically significant, but sample size is small; average cost for 12 calendar months following month of detox discharge

Learning From Local Models: CCC Recovery Housing

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Lower Total Health Care Cost with RH

Differences are statistically significant, but sample size is small; average cost for 12 calendar months following month of detox admission

Learning From Local Models: CCC Recovery Housing

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THE OPPORTUNITY• Collective investing could impact the gap in

need and care• Collective investing could be catalyst for

additional private investment + public policy shift

• Private investment leverages additional funding –$1 private investment could leverage $3+ from other sources

• Collective investment could make a dramatic difference in the lives of vulnerable populations; reduce repeat hospitalizations and other public costs; improve coordination, care and outcomes; stabilize lives; build self-sufficiency

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LOOKING AHEAD: OUTCOMES RESEARCH

Providence Center for Outcomes Research and Education (CORE) at Providence Portland Medical Center and the Center for Health Research at Kaiser Permanente :

• Housing retention• Employment Outcomes• Clinical Outcomes • Healthcare Utilization and Total Cost of Care• Opportunity for other cross sector

evaluation:• Education (School Days Missed)• Criminal Justice (Jail Days, Recidivism)

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QUESTIONS AND DISCUSSION

Thank you!

Sean Hubert

sean.hubert@ccconcern.org

Rachel Solotaroff

rachel.solotaroff@ccconcern.org

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Select ReferencesSupportive HousingIntegrating Housing & Health: A Health Focused Evaluation, The Apartments at Bud Clark Commons” Prepared for Home Forward by the Center for Outcomes Research and Evaluation (CORE), last modified April 14, 2014. http://www.portlandoregon.gov/phb/article/486815

Medical RespiteBuchanan D, Doblin B, Sai T, Garcia P. The effects of respite care for homeless patients: a cohort study. Am J Public Health. 2006 Jul;96(7):1278-81. Epub 2006 May 30. PubMed PMID: 16735635; PubMed Central PMCID: PMC1483848

End of Life CarePodymow T, Turnbull J, Coyle D. Shelter-based palliative care for the homeless terminally ill. PalliatMed. 2006 Mar;20(2):81-6. PubMed PMID: 16613403

Macroeconomic Conditions and Opioid AbuseAlex Hollingsworth, Christopher J. Ruhm, Kosali SimonNBER Working Paper No. 23192Issued in February 2017, Revised in March 2017

Where Have All the Workers Gone?Alan B. Krueger1Princeton University and NBEROctober 4, 2016

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BARRIERS TO SUDS AND MENTAL HEALTH SUPPORTIVE HOUSING• Lack of capital sources to support development of

clinic \ FQHC sites. • NMTC program extremely competitive, hard to

secure, and typically directed at rural communities.

• Perhaps make clinics LIHTC eligible (4%).

• Lack of operational support for integrated services. • Outpatient mental health and SUD treatment is

paid for. But remainder of care team including peer case manager, wellness navigator, housing specialist, and employment specialist are not.

• One approach would be to allow value of services to be capitalized upfront and included as part of LIHTC basis.

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BARRIERS TO SUDS AND MENTAL HEALTH SUPPORTIVE HOUSING• Key issue is economic re-integration.

• Great Recession knocked older and vulnerable populations out of employment, and as youth unemployment spiked kept younger Populations from entering workforce. Now both of these populations have added to chronically homeless populations.

• Investment in employment services should be expanded and viewed as key piece of long term housing stability and improved community reintegration.

• LIHTC integration. • LIHTC is primary affordable housing funding source

nationally. Need longer term services support (funding, grants) to better match 15 year LIHTC period.

• Investors want certainty that services funding will be in place long enough in order to get comfortable with project's population strategy (when special needs populations are proposed).